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Kardex: Date/ Time Medications Date Treatment/ Management

This patient was admitted on 4/26/20 at 8pm for prelabor rupture of membranes at 39 weeks gestation. Her treatment included ampicillin, dinoprostone gel, and hydration with D5LR. On 4/27, she received hydration and oxytocin for labor augmentation. Due to failure to descend, she underwent a C-section on 4/28 at 11am under Dr. Yu and Dr. Siton. Her post-op medications included ranitidine, metoclopramide, metronidazole, and tranexamic acid. Labs were drawn on admission and 4/27 at 5am. She received IV antibiotics and fluids during admission and was NPO in active

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Juviely Premacio
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613 views2 pages

Kardex: Date/ Time Medications Date Treatment/ Management

This patient was admitted on 4/26/20 at 8pm for prelabor rupture of membranes at 39 weeks gestation. Her treatment included ampicillin, dinoprostone gel, and hydration with D5LR. On 4/27, she received hydration and oxytocin for labor augmentation. Due to failure to descend, she underwent a C-section on 4/28 at 11am under Dr. Yu and Dr. Siton. Her post-op medications included ranitidine, metoclopramide, metronidazole, and tranexamic acid. Labs were drawn on admission and 4/27 at 5am. She received IV antibiotics and fluids during admission and was NPO in active

Uploaded by

Juviely Premacio
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd

KARDEX

DATE/ TIME MEDICATIONS DATE TREATMENT/ MANAGEMENT


4/26/20 @8pm 4/26/20
//1.)Ampicillin 2 grams IVTT (-)ANST now (8pm)// 2.(Ampicillin 2 -PLEASE ADMITPATIENT UNDER DR. YU
grams IVTT, ANST every 6 hours(8am-8pm- 2am-2pm)
3.)// Dinoprostone 0.5 mg gel endocervically (8:30PM)//
-SECURE CONSENT TO CARE
4/27/2020 -TPR q 4 hrs.
//4.) Give HNBB 1 amp + 1 cc sterile water Slow IVTT, 1st 2 doses at 1 -Pedia Dr. Pizarra
hour apart (5AM & 6AM) 1ST , 2ND // -Monitor progress of labor
- HNBB 1 amp + 1 cc sterile water Slow IVTT, every 4 hours (6AM- - O2 inhalation at 10 LPM via face mask
6PM- 10AM-10PM- 2AM-2PM)
//5.) HNBB 1 amp + 1 cc sterile water Slow IVTT, 1st 2 doses at 1 hour
4/28/2020 at 11:am
apart (5am & 6am)// then STAT 1ᵒ LSTCS 2ᵒ failure in descent
-HNBB 1 amp + 1 cc sterile water Slow IVTT q 4 hours (6am-6pm-10am- Secure consent to procedure
10pm-2am-2pm) Dr. Siton for anes –informed thru call
6.) Evening primrose oil 6 capsules per vagina (8:30pm) Inform pedia
PRE-OP MEDS 4/28/20 AT 11AM
1) Ranitidine 50 mg 1 amp IVTT on call to OR
Inform OR/DR
2) Metoclopramide 10 mg 1 amp IVTT on call to OR AP prep please
4/28/2020 at 12:55 PM Dr. Yu informed thru call
Metronidazole 500 mg IV drip now Primary consult done c ̅ Dr. Hermogenes
Tranexamic acid I gram IVTT now May go ahead with contemplated procedure

DATE/ TIME LABORATORIES DATE PARENTERAL MEDS/ IV FLUIDS


4/27/2020@ 5AM For CBC and U/A
4/26/20 // D5LR @ 30gtts/min//
4/27/20 //IVFTF: D5LR 1L at 30 gtts/min //
4/27/2020 at 3:20pm
// Run 200 cc of D5LR at MFD //
//IVFTF: D5LR 1L + 10 units oxytocin at 10 gtts/min
//
4/28/2020 at 3:15am
// Close off oxytocin drip //
//Hook PLR 1L in 200 cc as MFD then regulated at
30 gtts/min//
4/28/2020 at 4:45 am
//Close off PLR //
//Resume oxytocin drip at 10 gtts/min //
4/28/2020 at 11: 35am
Hold oxytocin drip Shift to PLR to ini 200 cc as MFD
then regulated at 30gtts/min
KARDEX
PATIENT’S NAME: Agapito, Rachel Saldivar DIET: DAT
AGE__23_____ SEX__FEMALE //NPO once active labor//
ATTENDING PHYSICIAN: DR.YU // DAT//
CO-MANAGEMENT___Dr.Hermogenes_______
DATE & TIME ADMITTED __4/26/2020
ROOM #______ RELIGION:_ROMAN CATHOLIC DIAGNOSIS/ IMPRESSION: G1P0 Pregnancy Uterine, 39
HOSPITAL #_____DATE OF BIRTH_10/27/1997 weeks AOG, Cephalic in latent phase of labor
BLOOD TYPE :_________ Prelabor rupture of membrane

CHIEF COMPLAINTS: Watery Vaginal Discharge

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